Modern lifestyles are leaving people feeling the pressure and struggling to sleep – so it is important to understand the health consequences of long-term stress and sleep disruption and be able to provide sleep hygiene and stress management advice.

Learning objectives

After reading this feature you should be able to:

  • Explain the links between stress and insomnia, and the health consequences of each condition
  • Advise on sleep hygiene and the importance of good quality sleep
  • Suggest ways to manage work-related stress.

 

Insomnia often goes hand in hand with stress. Research suggests that both these health problems are rapidly rising in the UK, fuelled by hectic modern lifestyles, increasing reliance on technology and household budgets that are feeling the pinch.

It is estimated that around half a million Britons experience work-related stress. And the World Association of Sleep Medicine says that one-third of adults suffer from clinically recognisable insomnia at some point in their lives. So what can pharmacists do to help customers cope with stress and get a good night’s sleep?

Nodding off

The exact purpose and function of sleep is something of a mystery, yet research suggests it plays an important role in growth, regeneration and memory. There is even evidence to suggest that humans would die quickly if completely deprived of it.

During a night’s sleep the brain passes through several cycles of five distinct stages. As someone drifts deeper into sleep, their brain waves become slower and they pass from stage one (drowsiness) to stage two (light sleep) into stages three to four (deep sleep), and finally stage five (REM or rapid eye movement sleep), which is when dreaming occurs.

Research has linked the different stages of sleep with different functions. For example, REM sleep seems to be associated with emotional well-being, whereas light sleep is believed to help consolidate memories. People who are deprived of this phase of sleep have trouble recalling things. A good night’s sleep is made up of the right balance of all these different stages.

Sleeplessness

Most people need about seven or eight hours of sleep a night to function at their best, although others can get by with less. Everyone suffers from sleeplessness or acute insomnia from time to time, which can lead to irritability, low mood and poor concentration the next day.

However, chronic insomnia is a medical condition and a significant risk factor for serious health problems, such as depression, high blood pressure, diabetes and obesity. It is typically defined as taking longer than half an hour to get to sleep or waking during the night for more than half an hour several nights a week for a month or longer and not feeling refreshed upon waking.

One thing is clear: insomnia is not just a nuisance but can have a major impact on a person’s health and quality of life. While people are becoming increasingly aware of the perils of lack of sleep, many still battle through their tiredness without seeking help because they do not believe it to be a serious health problem.

To help customers manage, it is important to establish whether the insomnia is due to an underlying psychiatric condition (e.g. depression), another sleep disorder (e.g. sleep apnoea), or whether it is a side-effect of medication. Once other conditions have been eliminated, the first step is to ensure that customers follow good sleep hygiene advice. If these measures fail, then medication or cognitive behavioural therapy may be considered.

It is important that pharmacists reinforce the health benefits of sleep when talking to patients with chronic diseases such as cancer. Sleep loss is associated with increased infections and lower immune system function. Living with long-term conditions also creates stress from coping with the illness, which can affect a person’s sleep. Click here for more information on sleeping problems in mesothelioma patients. (Mesothelioma is a cancer caused by exposure to asbestos.)

Sleep hygiene

Basic sleep hygiene is essential to help overcome both acute and chronic insomnia. This involves ensuring the sleeping environment is conducive to sleep and following a wind-down routine.

Taking a warm bath or shower half an hour before bedtime can help, as this will raise body temperature and then cause it to start falling again, which helps to bring on sleep. Other ways of preparing the mind for sleep include listening to relaxing music, taking a stroll or practising yoga or visualisation.

It is advisable to avoid stimulants, such as caffeine and nicotine, six hours before bedtime. Research shows that smokers can take up to an hour to get to sleep compared with non-smokers, who typically drop off within five to 15 minutes. While alcohol can help people relax and fall asleep quickly, it impacts on sleep quality and does not result in refreshing sleep.

The bedroom should be as comfortable as possible to promote sleep. Simple measures like changing quilts to match the season and using hot water bottles or electric fans can ensure room temperature is right for sleep. A thick, dark pair of curtains can block out sunlight or glaring streetlamps, while earplugs are effective at dampening noise.

There is also mounting evidence that sleeping surrounded by electronic devices such as mobile phones and tablets – or looking at them before going to sleep – can negatively affect sleep. Some experts believe that the blue light emitted from screens affects the production of the sleep-inducing hormone melatonin.

With research showing that almost a quarter of 16-24 year-olds and a fifth of people aged 25-34 years are browsing the internet and checking emails between 11pm-1am, it is not surprising that sleep disturbances are becoming more and more common. “People now often turn to devices as a means of distraction when they are struggling to drop off to sleep,” says sleep expert Dr Neil Stanley, “but this is likely to make the situation worse.”

There are three vital steps to ensuring a restful night’s sleep, he says. These are an environment conducive to sleep, a relaxed body and a quiet mind. “Going to bed and waking up at a regular time can also help to avoid sleep disturbances. When a person is out of a normal sleep pattern, OTC sleep aids can be helpful to re-establish a normal sleep rhythm.”

A medicated approach

OTC sleeping aids can be used in conjunction with sleep hygiene tips to treat short-term sleeplessness. Older generation antihistamines (e.g. diphenhydramine and promethazine) are effective, as they cause drowsiness. For those customers who prefer to take a herbal remedy, sleep aids are available containing blends of hops, valerian and passionflower, which are said to promote calmness and sleep.

Sleeping medication is frequently prescribed for severe sleep problems. Benzodiazepines and the ‘Z’ drugs, including zolpidem, zopiclone and zaleplon, are the most commonly prescribed sleeping agents. While they are often effective at promoting sleep, they can lead to dependence when taken long-term and can cause strong withdrawal symptoms when stopped.

Tolerance can be another problem, leading to increasingly high doses being needed to achieve an effect. For these reasons NICE recommends that sleeping medication should always be given at the lowest effective dose, for the shortest possible time, and be withdrawn gradually.

Unlike benzodiazepines, the ‘Z’ medicines are less likely to produce a ‘hangover’ effect the next day, so are considered preferable by the British Sleep Society, a professional organisation for medical, scientific and healthcare workers dealing with sleep disorders.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is often considered preferable to medication, as it tackles the root cause of insomnia and avoids problems with tolerance and dependence, but it may be difficult for patients to get referred to a specialist sleep clinic on the NHS. The therapy involves identifying dysfunctional beliefs and attitudes about sleep and replacing them with more adaptive alternatives.

A commonly used technique involves the patient keeping a sleep diary for several weeks to determine the average number of hours of sleep. The therapist may then recommend that they restrict themselves to this average for one night and then gradually increase it. For example, if they average five hours’ sleep a night but tend to wake up early, then they should go to bed exactly five hours before they need to get up.

Alternatively, sleepers who spend hours tossing and turning during the night before drifting off could try the ‘20-minute rule’. If sleep has not come after 20 minutes, they should get out of bed and do something else such as a jigsaw puzzle. This method may help to break their association between lying in bed and being unable to sleep.

Insomnia is usually triggered by stress but often remains even after the stress has been resolved because the insomniac has fallen into a pattern of staying awake during the night. The harder they try to sleep, the more it eludes them.

Lying awake while the mind runs through a long list of worries increases the activity of the nervous system, leading to a state of alertness. Insomniacs often add not being able to sleep to their list of worries, which only makes it even harder to sleep.

Pharmacy teams can advise customers to find some way of setting aside those worries for a while. One way might be to make a ‘to do’ list for the next day because, if a person’s thoughts are more organised, it might be easier to switch off.

 

People failing to make their ‘slumber number’

Over a quarter of people (26 per cent) believe they operate at half their capacity or less after a bad night’s sleep, according to research commissioned by Nytol. Some 46 per cent say they get stressed more easily and one in four people in full-time employment feel less in control at work after a poor night’s sleep. Forty per cent claim they “often feel tired”.

Half of those questioned were getting just six hours’ sleep a night – short of the ‘slumber number’ recommended by the Royal Society for Public Health (RSPH). For example, the RSPH recommends that 18-64 year-olds need an average of seven to nine hours a night.

One-third of people in full-time work (32 per cent) are losing sleep because they feel they have too many demands on their time, while 30 per cent are kept awake by unfinished ‘to do’ lists and 11 per cent by having too many emails in their inbox. A quarter of young adults (aged 16-24) claim they are often going to bed later than planned because they are working late and a third (33 per cent) stay up browsing the internet.

Many people are stuck in a vicious cycle, says sleep expert Dr Neil Stanley. “Poor sleep habits make people less productive in the workplace, and when suffering with sleepiness they often find it harder to make critical decisions. We then see people taking work home with them, sometimes working late into the night. This in turn can disrupt sleep for the following night.”
 
Product update
• Nytol Herbal Simply Sleep One-A-Night is a new traditional herbal medicinal product from Perrigo that can be used to provide temporary relief from sleep disturbances. It contains 385mg of valerian root extract.
• If sleeping problems persist beyond three to four weeks, a doctor should be consulted, says a spokesperson for Kalms Night. The product, along with Kalms Night One-A-Night, contains valerian root and should be taken up to one hour before bedtime.

Work worries

The number of people reporting work-related stress at a level that they believe is making them ill has doubled since the 1990s, so that over half a million people suffer from work-related stress, depression or anxiety today. Besides sleeping problems, stress is associated with a variety of health problems including palpitations, dizzy spells, increased sweating, headaches, aching muscles, nausea, indigestion and IBS symptoms.

“Everyone experiences bouts of anxiety, stress and sleep disruption as a result of short-term triggers like a job interview, relationship break-up or house move,” says Jane Devenish, NHS standards and services pharmacist at Well Pharmacy. “However, if this continues long-term, then a person’s health and quality of life can be negatively impacted.”

There are many different types of anxiety, she says. For some patients, their feelings of anxiety are related to specific triggers, such as a phobia or a traumatic event. Other patients suffer anxiety because of a panic disorder, characterised by unpredictable panic attacks, which can be caused by a number of factors including a traumatic experience, genetics, a chemical imbalance in the brain or ‘catastrophising’ minor physical symptoms.   

“For some patients their anxiety is not related to any one specific trigger or event but instead they experience excessive worry about many aspects of their life that lasts for at least six months. Symptoms of this generalised anxiety disorder include irritability, tiredness, dizziness, a sense of dread and insomnia. 

“It is important community pharmacists understand the difference between these forms of anxiety so they are able to give appropriate advice and know when to signpost on to another healthcare professional,” says Devenish.

“Patients can make a number of lifestyle changes to improve their anxiety levels, such as increasing their exercise; eating a healthy diet, especially foods containing B vitamins, omega 3 and 6, magnesium and calcium; getting outside to ensure vitamin D levels are kept high enough; meditating or using deep breathing relaxation techniques; and practising good sleep hygiene.”

There is a strong link between sleep disorders and psychiatric disorders, and taking steps to get restful sleep can make a significant difference to anxiety, says Devenish.

MIND, the mental health charity, suggests sufferers of daily stress be given the following advice:
• If you are a ‘morning person’, then try to carry out your most important tasks early in the day. If you are at your best in the evening, leave them until later
• When you are feeling snowed under, make a list of everything you’d like to get done in order of priority and stick to the order
• Tackle tasks one at a time – not all at once
• Mix up the interesting tasks with the dull ones and the tricky tasks with the easy ones – and take breaks in between
• Learn to say no when faced with unrealistic demands
• At the end of each day reflect on what you’ve achieved rather
than fret over what you didn’t manage to do
• Spend your free time relaxing or doing an absorbing hobby or sport
• Release your stress through plenty of exercise.

The exact purpose and function of sleep is something of a mystery

 

Bladder weakness and sleep

Getting a good night’s sleep can be a challenge for women experiencing bladder weakness problems and can be a cause of concern that often translates into an inability to fall asleep or remain asleep (writes Donna Wilson, TENA training and brand manager).

The resulting stress and anxiety coupled with the physical discomfort that can arise from night-time bladder weakness (nocturnal enuresis), means that it is important pharmacy teams are able to advise on appropriate bladder weakness products, which are specifically designed for peace of mind at night.
Insomnia and bladder weakness

Research from TENA Lady has revealed that one in six women in the UK experience bladder weakness at night, with 42 per cent admitting that needing to go to the toilet regularly disturbs their sleep.

A pharmacy customer’s sleep might also be disrupted because they are not using the most appropriate protection for their needs – for instance, using a product at night that is designed for use during the day.

One of the biggest emerging trends in the bladder weakness category is growth in the night segment. But there is still substantial untapped potential for pharmacists looking to drive incremental sales, since only one in 10 women currently opt for a specific night-time product.

Product recommendations

The TENA Lady night-time range comprises three products: TENA Lady Mini Night, TENA Lady Maxi Night and TENA Lady Pants Night. TENA Lady Mini Night is a new innovation for light to medium bladder weakness that is body-shaped for comfort. Each pad offers extra absorbency when lying down.

Another possible recommendation is TENA Bed Protectors, which are available in different absorbencies and sizes. These disposable pads offer hygienic protection for beds and mattresses against accidental leakages.

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